Provider Demographics
NPI:1588635783
Name:KELLY, MICHAEL A JR (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:KELLY
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 2ND AVE SW
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-3629
Mailing Address - Country:US
Mailing Address - Phone:701-837-5733
Mailing Address - Fax:
Practice Address - Street 1:1415 2ND AVE SW
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-3629
Practice Address - Country:US
Practice Address - Phone:701-837-5733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND749111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND13529Medicaid
NDV01099Medicare UPIN
ND13529Medicaid
ND24752Medicare ID - Type Unspecified